Dear Robyn, Mandie and all

This ongoing discussion is fascinating and important, thank you.  To answer your question, Robyn, no, I'm afraid I'm one of those irritating people who has identified something that I think is an issue, without coming up with any clear answers.  I've thought about it a lot, and think that solutions will be complex and will take time.  For example, I think a lot of what happens in practice is tied up with gender politics i.e. midwives, who are predominantly female, learn gendered behaviour patters from infancy that are played out and upheld in societal norms.   Solutions to building strength and confidence in midwives may therefore involve a radical rethink of the ways in which girls are raised and educated in society etc etc   However, I think that it may also be useful to teach politics and gender as an explicit part of the midwifery curriculum, to encourage students to have more self-awareness about how and why they work as they do, and how and why they might challenge the system.  I would love to hear from other group members to see what they suggest.  This ties in with Mandie's comment about midwives being a 'politically muted group'.  

I know it is all too easy for me to appear to criticise midwives who record vaginal examinations that are 'untrue' and that, in any case, notions of 'truth' are, in themselves, subjective.  I think it is absolutely true (!) that midwives who do alter the findings of a vaginal examination, in order to give a woman more time in the second stage will, in many cases, protect that women from unnecessary intervention which surely is a good thing to do.  However, this comes back to my point that, by practising in this very hidden way, the current system remains unchallenged and therefore many women will continue to have intervention because they have been actively pushing for more than an hour (or whatever the policy of that unit may be).  

I know how hard it is to challenge the system - it takes courage, patience, time, persistence etc.  However, there is also a risk that we, as midwives, can make ourselves into victims - that is, we can tell ourselves that we are too small, too powerless etc and it is easier just to carry along as always have done (which is undoubtedly the case).  

So where next?  I'm really not sure.  I know I am being quite provocative and contentious but would love to continue this discussion about notions of 'truth', power and midwifery practice via the fabulous resource of the discussion lists.

Very best wishes

Mary




Research Midwife
Birthplace Study
National Perinatal Epidemiology Unit
University of Oxford
Old Road Campus
Oxford
OX3 7LF
 
Tel: 01865 289732
 
http://www.npeu.ox.ac.uk/birthplace
 


>>> Robyn Maude <[log in to unmask]> 5/12/2010 11:53 am >>>
This is really what I was alluding to - midwives hiding/subverting findings
- it is fascinating and I am pleased to hear you have researched it. I think
we see examples of this across a broad spectrum of practice

You say "
I don't think this is 'doing good by stealth' - it's dishonest and
unhelpful"

What can we do to build strength and confidence in midwives to say it like
it is and defend whatever it is they are trying to do/achieve by the
stealth, especially within the maternity unit?

Robyn



-----Original Message-----
From: The normal birth research list
[mailto:[log in to unmask]] On Behalf Of Mary Stewart
Sent: Wednesday, 12 May 2010 9:45 p.m.
To: [log in to unmask] 
Subject: Re: Breech presentation

Dear all

Thank you for your e-mail, Belinda, and for generating such an interesting
discussion.  As others have remarked, it is shocking that the Trust is
considering the implementation of routine scans in labour for all
nulliparous women.

I wanted to follow up on the discussions around midwifery practice, and the
question of whether midwives falsely record a cephalic presentation in order
to try to protect women from unnecessary intervention.  This 'fits' with one
of the findings of my PhD, which explored midwives' experiences of vaginal
examination in labour.  The midwives I interviewed all spoke about the
practice of falsely recording a vaginal examination - this was something
they had either done themselves and/or witnessed other midwives doing.  The
most common example midwives described was a scenario where a vaginal
examination indicated that the cervix was fully dilated but the midwife
recorded that it was only 9 (or 8 ...) cms dilated.  Midwives did this in
order, as they described it, to 'buy time' i.e. to try to avoid an
instrumental birth for 'delay' in the second stage.

This practice of hiding/subverting midwifery knowledge is fascinating and
hugely problematic.  The midwives I interviewed all believed, with great
sincerity, that they were protecting the woman's best interests and that
they were providing woman-centred care.  However, there are several points
to consider:
1) Working in this way simply sustains dominant belief  systems.  In
relation to vaginal examination, it upholds current beliefs about the length
of labour, rather than challenging them. 
2) The midwives in my study did not involve women in the decision to falsely
record vaginal examination and therefore I don't accept that this is
woman-centred practice. 
3) This is a highly subversive way of working.  I believe passionately in
the important of evidence based practice (by which I mean all types of
evidence, qualitative and quantitative).  We, as midwives, need to have the
courage and integrity to expose our own knowledge and practice to scrutiny,
rather than hiding it away and practising in a way that is, ultimately,
dishonest.

Sorry, this is rather a long e-mail but if, as others have suggested,
midwives may be recording a cephalic presentation when they know this is
untrue, I don't think this is 'doing good by stealth' - it's dishonest and
unhelpful and, as Belinda's e-mail starkly illustrates, can lead to more
rather than less intervention.

Very best wishes

Mary




Research Midwife
Birthplace Study
National Perinatal Epidemiology Unit
University of Oxford
Old Road Campus
Oxford
OX3 7LF
 
Tel: 01865 289732
 
http://www.npeu.ox.ac.uk/birthplace 
 


>>> "Benn, Cheryl" <[log in to unmask]> 5/12/2010 12:12 am >>>
I agree with both your comments. I have had women diagnosed with breech and
booked for an elective section who then go into labour before the booked
section date. While in labour I have tried to delay them going to theatre in
the hope that they can birth vaginally but then I have to ask whether that
is what the woman wants or what I want.
Cheryl Benn

-----Original Message-----
From: The normal birth research list
[mailto:[log in to unmask]] On Behalf Of Makeda Kamara
Sent: Wednesday, 12 May 2010 10:51 a.m.
To: [log in to unmask] 
Subject: Re: Breech presentation

I think you might be on to something Robyn.  I know that myself and 
several collegues during certain circumstances do that to protect the 
woman.


-----Original Message-----
From: Robyn Maude <[log in to unmask]>
To: [log in to unmask] 
Sent: Tue, May 11, 2010 5:27 pm
Subject: Re: Breech presentation



Hi Soo
Is the diagnosis of breech  being 'missed' during labour?
Or is it midwives' passive way of backlash against stringentpolicy 
around vaginal breech birth and CS?
Just a thought, But I think we are getting women and midwiveswho fly 
under the radar on these things in the hope it will be too late to 
havethe CS in supporting women to maintain some control over their 
births
 
Robyn
 

 From: Thenormal birth research list 
[mailto:[log in to unmask]] OnBehalf Of Soo Downe
Sent: Wednesday, 12 May 2010 4:55 a.m.
To: [log in to unmask] 
Subject: Fwd: Re: Breech presentation

 


>>> Belinda Cox <> 5/11/2010 5:13 pm >>>




 "Belinda  Cox" <[log in to unmask] 








Dear all,



 



Apologies for    cross posting this.



 



I really need    some advice and support here - I'm almost in tears!!



 



The Trust I    work for has identified that we're having an increased 
number of women    diagnosed with breech presentation in established 
labour, and are exploring    the implementation of scanning all 
nulliparous women on admission in labour    to confirm presentation!!



 



My view is that    we need to look at why the presentation isn't being 
confirmed  PRIOR    to labour if there's a query about it (e.g USS), 
and then if breech    presentation is confirmed offering appropriate 
counselling and ECV. IF a    woman chooses to have a CS for breech 
presentation it's better that    she gives true consent (not in labour) 
and that it's done electively and    calmly rather than her being 
'encouraged' to have an emergency CS    in labour.



 



Have any other    Trusts identifed this as a problem? does anyone have 
any teaching or    assessment tools that they use which would support 
the midwives and    obstetricians to decrease the number of breech 
presntations that are missed    prior to labour?



 



Any other    thoughts on this?



 



Best wishes,



 



Belinda